Scenario: You are seeing a 34-year-old multi-race female who is a school counselor.
She reports a 3-day history of a sore throat, rhinorrhea, nasal stuffiness and postnasal drip.
She states she thinks she may be running a low-grade fever but reports she has not actually taken her temperature.
She reports feeling tired.
She has a history of migraine headaches for which she utilizes ibuprofen as needed. She has a script for Maxalt if needed however reports she hasn’t used that in several years.
She is on hormonal contraceptive management. BP 112/66, P 68, Resp 18, Temp 98.7, SpO2 99% on RA
On your exam you note clear nasal discharge, tympanic membranes are pearly gray, posterior pharynx is erythematous, no tonsillar enlargement noted.
Breath sounds are clear bilateral.
Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion.
Utilize the information provided in the scenario to create your discussion post.
Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).
Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]
Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
Support the interventions outlined in your ‘P’ with scholarly resources.
Please be sure to validate your opinions and ideas with citations and references in APA format.
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